and What It Means to Your IRF

Understanding the PEPPER

FIM, UDS-PRO, and UDSMR are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

Sue Gehrman, RN

Regional Director of Operations and Clinical Services

Charlotte, NC

Carol Daubner

Vice President of Client Financial Services

Houston, TX

MILESTONE HEALTHCARE is based in Richardson, Texas, and provides management and consulting services for:

IRFsLTACsSNFs

GeropsychTherapy staffingNurse staffing

Can It Mean Heartburn? Or Will It Be

the Spice of Life?

Objectives

1. Provide insight into what the PEPPER is.2. Provide an understanding of each target area

and why it was identified as an indicator.3. Provide meaning to the established targets and

implications.4. Explore ideas on how to use the UDS-PRO®

System to reverse established negative trends.5. Communicate potential opportunities for IRFs

using the PEPPER.Knowledge of where you are, where you are going, and where you want to be is essential for reaching your intended destination.

Who?

TMF Health Quality Institute, under contract with CMS, began providing the PEPPER to acute care hospitals in January 2010

The initial IRF PEPPERs were released in September 2011 for the most recent twelve federal fiscal quarters (April 1, 2008, to March 31, 2011)

The most recent PEPPER for IRFs was released on March 23 for the period from October 1, 2008, to September 30, 2011

Next PEPPER will be released in September 2012

What?

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a Microsoft® Excel file that contains hospital-specific data statistics for target areas often associated with Medicare improper payments due to billing issues, CMG coding issues, and admission necessity issues

The PEPPER compares an IRF’s data to that of the state, the IRF’s MAC jurisdiction, and the nation to identify aberrant patterns

Where?

Freestanding IRF PEPPERs were distributed in hardcopy format to hospital CEOs

Distinct-part units within hospitals had their PEPPERs distributed via My QualityNet to each hospital’s QualityNet administrator’s web account

IRF PEPPERs will be distributed semiannually – The next is due on or about September 25,

2012

Why?

We are currently in an “era of medical reviews”– Quality initiatives– Performance measures – Data collection and

reporting– Pay for performance

The PEPPER does not identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts– Compare claims over

time– Identify areas of

potential concern– Identify changes in

billing practices

How?

All data statistics are collected from the paid inpatient Medicare UB-04 claims processed by the MAC (Medicare administrative contractor) or FI (fiscal intermediary)

It compares the facility’s data with state, MAC jurisdiction, and national data

IRF Target Areas

These PEPPER target areas were approved by CMS because they have been identified as potentially prone to improper Medicare payments in IRFs

How Risk Is Calculated

Reportable data: There are eleven or more numerator discharges for a given target area for given time period (if fewer than eleven, statistics are not displayed in the PEPPER)– Numerator: Discharges identified as

potentially problematic in reference period– Denominator: Total discharges for reference

period (includes numerator)

How Risk Is Calculated

Percentages:Number of cases targeted x 100 = PercentageNumber of total discharges

Percentile:– Percentage of IRFs with a lower target area– Ranks facility and compares nation, MAC/FI

jurisdiction, or facility’s state

How Risk Is Calculated

If the IRF’s target area percentage is at or above the 80th percentile, the IRF is identified as an “outlier” or outside the “norm”

80th

PercentileIdentified in RED BOLD PRINT on the PEPPER

Miscellaneous CMGs

Potentially prone to “unnecessary” IRF admissions

CMG Weighted Motor Score on Admission2001 M > 49.152002 M > 38.75 and M < 49.152003 M > 27.85 and M < 38.752004 M < 27.85

Impairment Group Codes That Fall to CMG 2001–2004

Congenital Deformities: 12.1 Spina Bifida 12.9 Other Congenital

Other Disabling Impairments: 13 Other Disabling Impairments

Developmental Disability: 15 Developmental Disability

Debility: 16 Debility (Non-cardiac,

Non-pulmonary)

Medically Complex: 17.1 Infections 17.2 Neoplasms 17.31 Nutrition with Intubation/Parental

Nutrition 17.32 Nutrition without

Intubation/Parental Nutrition 17.4 Circulatory Disorders 17.51 Respiratory Disorders – Ventilator

Dependent 17.52 Respiratory Disorders –

Non-ventilator Dependent 17.6 Terminal Care 17.7 Skin Disorders 17.8 Medical/Surgical Complications 17.9 Other Medically Complex

ConditionsThe impairment group codes referenced on this slide are the property of UDSMR.

Suggested Analysis If You Are at or above the 80th Percentile

Is it clear in the documentation that the patient’s admission to rehab was “reasonable and necessary,” as defined by the criteria?

Could the patient be appropriately treated in a lower level of care (OP, SNF, HH)?

Focus on why the patient needed an acute level of care and functional improvements

CMGs at Risk for Unnecessary Admissions

CMGs: 0101, Stroke 0501, Non-traumatic SC 0601, Neurological 0801, Replacement of LE Joint 0802, Replacement of LE Joint 0901, Other Orthopaedic 1401, Cardiac 1501, Pulmonary

No tier group assignment

A

Suggested Analysis If You Are at or above the 80th Percentile

Review list of comorbid conditions for tiers, and educate physicians and pre-admission nurses

Was it a necessary admission?– Could the patient have been treated

appropriately in a lower level of care (OP, SNF, HH)?

Were the admission FIM® ratings correct?– All indicate an admission motor FIM® rating

greater than 44–51

Suggested Analysis If You Are at or above the 80th Percentile

What are the scoring competencies and processes for late/weekend admissions?

Are you capturing the true “burden of care”?

Outlier Payments

Complex set of calculations that are not easily understood or controlled on the clinical operations of the IRF

CMS sees outlier payments as “excessive” and potentially fraudulent or improper

Clinical and finance departments must work together to analyze the problem and understand the issues

Outlier Payments

Problem: – Facility is submitting a high percentage of

claims that result in outlier payments– What causes the “overpayment”?– Is this an “appropriate” patient for an IRF?

Outlier Payments

2012 threshold for outlier payment: $10,713 FR CN CMG example: D0108, Stroke (LOS 23 days)

– Payment for CMG D0108 = $26,222– Assume high charges $80,000 (diagnostics,

dialysis, drugs)– CCR 0.4850 x charges = $38,800 (“cost”)– $38,800 – ($26,222 + $10,713 ) = $1,865 – $1,865 x 0.80 = outlier payment of $1,492

Total payment = $26,222 + $1,492 = $27,714

Suggested Analysis If You Arenear, at, or above 80th Percentile

Any reimbursement analysis must involve your finance department– Accurate cost-to-charge ratio (CCR)How is it determined?

– Review of chargemaster– Room rates– High ancillary charges– Low volume– High-cost patients

Suggested Analysis If You Arenear, at, or above 80th Percentile

Any reimbursement analysis must involve your finance department– Long LOS– Complex patients can be costly—are they

appropriate for inpatient rehabilitation? Some are expected—the latest PEPPER data

shows that the national 80th percentile is 26.2%

STACH Admissions following IRF Discharge (within 30 Days)

Does not include patients transferred back to acute care for medical complications during IRF admission

Indicates that a patient is not medically stable or prepared for discharge

Includes patients discharged to SNFs who come back to the acute hospital

Not easily tracked or known to the IRF, especially if a patient is admitted to another facility

Suggested Analysis If You Are at or above the 80th Percentile

Look at your discharge FIM® ratings– Do your patients meet the goals?– Examine the FIM® Profile Report at 50th

percentile target goals Discharge planning and patient/family education

– Are you overlooking opportunities and needs? Are discharges to skilled nursing appropriate?

Suggested Analysis If You Areat or above the 80th Percentile

Do you follow up with patients immediately after discharge?– How are they doing?

Combine your efforts with acute care on their PEPPER’s standing on readmission rates– Could provide an opportunity for referrals to

rehabilitation

Nationwide Target AreaSummary of Cost Involved

Target Area Q2 FY 2011Miscellaneous CMGs $735,331,278CMGs at risk for unnecessary admissions $136,058,580Outlier payments $642,455,804STACH admissions following IRF discharge $848,762,853

Total dollars spent $2,362,608,515

Top CMGs

Two New Listings Distributed: #1

Top jurisdiction CMGs for most recent four quarters– Includes all tiers (A, B, C, and D)– Total discharges– Proportion of discharges for each CMG to total

discharges– Jurisdiction average length of stay for CMG– Must have at least eleven discharges per CMG

Top CMGs for Jurisdiction

Two New Listings Distributed: #2

Top IRF CMGs for most recent four quarters– In descending order by totals per CMG– Must have had at least eleven discharges in

the most recent four quarters– Includes all tiers (A, B, C, and D)– Total discharges for each CMG per facility– Proportion of discharges for each CMG to total

discharges– Facility average length of stay for CMG

Why Are These Listings Important?

How much do you vary from the norm? Why?

– Programs– Services– Coding practices

UDSMR® On-Demand Reports

Profile Report– Use 50th percentile for goal targets

Rehab Metrics Report– Use comparative time frames– Only include Medicare non-MCO

Percentage of Cases by Comorbidity Tier Report

Resources

Handouts:– List of top CMGs– Sample FIM® Profile Report– Common comorbidity tiers for 2011– PEPPER website info

Resources

References:– PEPPER User’s Guide, First Edition;

www.pepperresources.org– Inpatient Rehab to Get First PEPPER Data in

September as Medicare Concerns Grow; Report on Medicare Compliance, Vol. 20, #31, Sept. 5, 2011

– PEPPER Is Back: Using Medicare Data Reports for Auditing and Monitoring; March 2010. www.hcca-info.org

Resources

References:– Utilizing PEPPER Data to Support Your

Compliance Efforts; August 17, 2011. www.racmonitor.com

– Using the New Inpatient Rehab Facility PEPPER to Support Auditing and Monitoring Efforts; Kim Hrehor; September 23, 2011, CMS Webinar

– Using UDSMR® On-Demand Reports to Track PEPPER Areas; Maggie Divita, UDSMR®

Webinar, November 2011

Don’t Be Afraid to “Spice up Your Life”

Stumbling blocks:– Initial fear– Feeling overwhelmed– Midway slump (“This is not fun!”)– Dropout rate: 90% vs. 10%

Take-away: Sit down with your TEAM to really understand the PEPPER for your facility

“To be happy, we need to find a balance between comfort and adventure.” —Mary Jaksch

Thank You!

Sue Gehrman:– sue_gehrman@milestonehealth.com– 214-535-1159

Carol Daubner:– carol_daubner@milestonehealth.com– 281-272-9027